AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Prolapse of the rectum is one of the first surgical entities described in the medical profession and can be defined as the protrusion of all layers of the rectal wall through the anal sphincter (see Media file 1).
 
The first description of rectal prolapse and its etiology is attributed to Moschcowitz in 1912. Rectal prolapse in childhood was first highlighted by Lockhart-Mummery in 1939.¹ He attributed it to malnutrition and careless nursing but also acknowledged diarrheal and wasting illnesses as contributing factors. His preferred operative treatment was linear cauterization of the prolapsed rectum, with recurrences treated by 5% phenol injection. In adults, rectal prolapse is 6 times more frequent in females than in males. Almost all patients have a history of constipation (75%), which stretches the pelvic floor and the anal sphincter mechanism, predisposing them to rectal prolapse.
 
In children, the incidence is higher during the first year of life, after which it becomes increasingly infrequent. It is slightly more common in boys than in girls. Whether prolapse in children is predominantly mucosal (procidentia) rather than full thickness is controversial.
 
Loss of the normal sacral curvature that causes a vertical tube between the rectum and the anal canal has been described as a causative factor. Straining during defecation predisposes children with constipation, diarrhea, or parasitosis and those who use laxatives to prolapse. About 60%-70% of the patients have fecal incontinence.² The prolapse can spontaneously reduce or it can be digitally reduced. 
 
One classification divides the entity. In true prolapse, all layers of the rectum are protruding; in procidentia, only the mucosa is herniated. However, this classification is confusing and nonspecific; thus, it should be abandoned.

Altemeier et al described the most widely used classification in 1971. He divides the entity in 3 types, as follows:³

• Type I is the protrusion of redundant mucosa, termed false prolapse. It is usually associated with hemorrhoids.
• Type II is an intussusception without sliding hernia of the cul-de-sac. The intussusception occupies the rectal ampulla but does not continue through the anal canal. The most common symptom is fecal incontinence; solitary ulcers in the anterior rectal mucosa can be seen.
• Type III is complete prolapse that includes full-thickness rectal prolapse. It is associated with a sliding hernia of the Douglas pouch and is the most frequent type.

History of the Procedure

• Altemeier et al described their perineal approach in 1971, which involves anterior closure of the pelvic diaphragm and transanal resection of the prolapsed segment with anastomosis.³
• Ripstein and Lauter addressed the problem of prolapse by suspending the rectum via an abdominal approach.⁴
• Ashcraft and Holder reported their experience with posterior repair in 46 children over a period of 17 years, with resolution in 42 patients.⁵ Three of the failures were attributed to sigmoid intussusception. This outcome highlights the importance of delineating this from rectal prolapse preoperatively.
• Some authors have reported excellent results with injection sclerotherapy.^{6, 7}

Problem

Rectal prolapse is an uncommon disease in Western children. Most cases are self-limiting, characterized by prompt resolution with institution of conservative measures aimed at correcting associated underlying problems, such as constipation and straining. Rectal prolapse in children is thought to begin as mucosal prolapse starting at the mucocutaneous junction, which may eventually progress to full-thickness prolapse.

Frequency

The incidence of rectal prolapse has decreased over the years due to improved nutrition and hygiene. Rectal prolapse in childhood occurs most commonly in children younger than 4 years, with the highest incidence in the first year of life.

Etiology

The exact etiology of rectal prolapse in children is unknown. However, several predisposing factors have been identified. The most common underlying condition is chronic constipation and straining (52%). Other causes include diarrhea (15%),⁸ rectal parasites (the most common cause of rectal prolapse in the developing world), neuromuscular disorders, pelvic nerve disorders, myelomeningocele, bladder and cloacal exstrophy, Hirschsprung disease, high anorectal malformation, cystic fibrosis, chronic coughing, lymphoid hyperplasia, rectal polyps, and shigellosis.

Broden and Snellman proposed a theory to explain the etiology of rectal prolapse.⁹ They cineradiographically demonstrated that the entity implies a circumferential intussusception of the rectum, with its origin 3 inches above the anal margin.

Pathophysiology

Rectal prolapse has been associated with a myriad of conditions, including fecal incontinence and diarrhea,^{8, 10} chronic constipation,¹¹ neuromuscular disorders, mental challenge,¹² poor sacral root innervation (such as is observed in spina bifida), bladder or cloacal exstrophy,¹³ scleroderma,¹⁴ Hirschsprung disease (especially in the ultrashort aganglionic segment, which acts as a suboclussion, favoring the appearance of rectal prolapse),¹⁵ rectal polyps (in which the polyp acts as a leading point for the intussusception),¹⁶ and cystic fibrosis.¹⁷ Cystic fibrosis deserves special mention because rectal prolapse is found in as many as one fifth of patients and can be the presenting symptom in as many as one third. Potential mechanisms in which this condition predisposes an individual to prolapse include voluminous or bulky bowel movements, coughing paroxysms, and undernutrition.

Other implicated entities include lymphoid hyperplasia of the distal colon, which also acts as a leading point for the rectum to intussuscept,¹⁸ parasites and infectious agents,^{19, 20, 21} and human immunodeficiency virus (HIV) infection.²²

Several important anatomic variants contribute to the incidence of rectal prolapse in early childhood. These include loose attachment of redundant rectal mucosa to the underlying muscularis; vertical configuration of the pelvis and sacrum; increased mobility of the sigmoid colon; the lack of Houston valves (75% of infants younger than 1 y), which might explain the higher incidence of rectal prolapse in the first year of life; and relative lack of support by the levator ani muscle.

Clinical

History

Parents usually observe rectal prolapse as a red ring of mucosa protruding from the rectum after the child defecates. This finding is often associated with tenesmus and mucus or bloodstained clothing (see Media file 2). Constipation is present in 25%-50% of individuals; as many as 75% present with fecal incontinence. Initially, the prolapse occurs with defecation and straining. As the pelvic floor musculature becomes more lax, the rectum may prolapse with the mildest straining, an upright position, or even spontaneously at rest. Most prolapses spontaneously reduce; however, the parents (or patient) occasionally have to manually reduce the prolapsed bowel.

A history of neonatal stooling problems or a family history of cystic fibrosis should be elucidated.

Physical examination

The primary care physician should initially approach rectal prolapse as a symptom rather than a specific disease entity and should always search for an underlying disorder. Anatomic causes, such as Hirschsprung disease and previous imperforate anus, should be ruled out. Constipation, diarrhea, parasitic infections, polyps, anal stenosis, and, most importantly, cystic fibrosis should be considered. Clinical clues to cystic fibrosis include oily, malodorous, or floating stool; a poor growth pattern; wheezing or other respiratory symptoms; and digital clubbing. Examine these patients in a sitting position while straining because other positions (jackknife or left lateral decubitus) are frequently inadequate to reproduce the prolapse.

Upon examination, the typical prolapsed rectum is a pouting, swollen rosette. In the case of a false or mucosal prolapsed (procidentia), the prolapsed tissue has radial folds at the anal junction; whereas a full-thickness prolapse has circular folds in the prolapsed mucosa. If the rectum is prolapsed at the time of examination, palpation of the prolapsed mucosa between the finger and thumb allows the examiner to distinguish between mucosal and complete rectal prolapse (see Media file 7-8).

Differential diagnosis

The differential diagnosis of rectal prolapse includes prolapsing rectal polyp. This appears with defecation and spontaneously reduces. Digital examination enables the clinician to differentiate this from rectal prolapse because the lesion does not involve the entire circumference. Patients with recurring rectal prolapse with no apparent cause or a history of rectal bleeding should undergo proctosigmoidoscopy to rule out polyps.

Ileocecal intussusception, although theoretically a differential diagnosis, should be evident from the history and examination of the patient.

Submucosal venous congestion secondary to straining may manifest as an intermittently appearing anal lesion and might be confused with rectal prolapse.

Hemorrhoids are another differential diagnosis; however, these are uncommon in pediatric patients and are usually only observed in the setting of portal hypertension.

Rectal tumors are infrequent in the pediatric population.

Reduction

If prolapse is present at the time of examination, reduction should be promptly performed before the onset of edema. If edema is already present, gentle sustained pressure may be necessary. Digital rectal examination after reduction should be performed to ensure complete reduction. If prolapse recurs immediately after reduction, the buttocks should be taped.

First, the prolapsed mucosa becomes edematous due to lymphatic obstruction. If the process is not reversed at this stage, venous obstruction ensures and accelerates and aggravates the edema (see Media file 3), leading to arterial vessels obstruction with subsequent necrosis. Reduction must be promptly performed because, once the bowel becomes necrotic, emergency surgical resection is required. When the reduction has become difficult because of profuse edema, the use of topical table sugar has been described to help decrease the edema and facilitate reduction.^{23, 24}

Rare sequelae of rectal prolapse include solitary rectal ulcer syndrome²⁵ and inflammatory cloacogenic polyp. Both are presumed manifestations of ischemia secondary to prolapse and are rare in children.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Surgery is infrequently required for rectal prolapse. However, if the prolapse persists after an adequate trial of medical therapy (usually a period of months), surgical intervention may be required. Age, duration of conservative management and frequency of recurrence ought to be taken into consideration. Pain, excoriations, and rectal bleeding are considered surgical indications.

If a patient has a prolapse when presenting to the emergency department and it cannot be reduced, or if necrosis is already present, emergent surgical resection is indicated. If a recurrent prolapsed rectum is successfully reduced in the emergency department, surgery is scheduled within the next 2 weeks to allow the edema to subside before the procedure.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

The anal canal extends cephalad from the anal verge to the anorectal ring. The rectum extends from this point to the sacral promontory. Upon histologic examination, the anal canal consists of mucosa, submucosa, and 2 muscular layers: the internal anal sphincter (IAS), which is a continuation of the circular muscle of the rectum, and (2) the external anal sphincter (EAS), which lies outside the IAS as an elliptic cylinder and is continuous with the puborectalis muscle superiorly. The surgical anal canal includes this entire muscular sphincter mechanism (see Media files 4-6).

The many and varied procedures described for the treatment of rectal prolapse attempt to create a fixation of the anorectal mucosa and/or wall to the submucosa and/or perirectal tissues.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

No absolute contraindications are reported for the surgical management of rectal prolapse in childhood. However, an adequate trial of conservative measures should precede surgical therapy because this suffices in most patients, especially those with cystic fibrosis and rectal prolapse, in whom appropriate dietary manipulation and pancreatic enzyme therapy are usually sufficient.

The only absolute contraindication for surgery is poor general medical condition of the patient, which precludes a major operation. After a prolapsed rectum is successfully reduced in the emergency department, the procedure should be scheduled within the next 2 weeks to allow the edema to resolve.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Lab Studies

• Cystic fibrosis is an important cause of rectal prolapse in children and should be considered in certain patients who present with rectal prolapse. Clinical clues to cystic fibrosis include oily, malodorous, or floating stool; poor growth pattern; wheezing or other respiratory symptoms; and the presence of digital clubbing.
• Results of sweat chloride testing and genetic testing confirm the diagnosis.
• Because of the potentially disastrous consequences of missing the diagnosis of cystic fibrosis and because of the improved prognosis associated with early diagnosis and institution of treatment, determining the sweat chloride concentration in certain patients presenting with rectal prolapse may be useful.
• The absence of respiratory symptoms and normal findings upon physical examination do not exclude this possibility.

Imaging Studies

• Sigmoid intussusception rarely presents as rectal prolapse in pediatric patients.
• Ashcraft et al (1990) highlighted the importance of preoperative diagnosis to prevent inappropriate initial treatment and postoperative recurrence.⁵ Two patients in their series of 46 required subsequent sigmoid resection. Preoperative barium enema with a defecating view revealed a coiled-spring appearance typical of sigmoid intussusception.
• Defecography (ie, videofluoroscopy of the barium-filled rectum during defecation) can be used to identify rectal prolapse or intussusception.
• A contrast enema study may be needed to look for polyps or other leading points.

Other Tests

• Children with symptoms that suggest rectal polyps should undergo proctosigmoidoscopy for diagnosis confirmation, to obtain biopsy samples when applicable, and to rule out a leading point in the case of intussusception.
• The clinical and cost benefit of routine preoperative anal manometry, pudendal nerve motor latency, colonic transit, and defecography is unclear.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Medical therapy

In patients with diarrhea and constipation, rectal prolapse usually resolves when the stool pattern returns to normal. Therefore, constipation should be aggressively managed. Antiparasitic agents should be used when parasitic organisms are found.

Further management should focus on parental reassurance and education. Instruction on how to reduce a prolapse may prevent repeated presentations to the emergency department. The type of toilet that the child uses is also important; use of an adult toilet contributes to rectal prolapse because the buttocks are in a dependent position and the feet are unsupported. Using a special child's toilet or using a step to support the feet are useful adjuncts to treatment. Time spent on the toilet should also be limited to minimize straining and pushing.

In patients with cystic fibrosis, initiation of adequate pancreatic enzyme replacement usually results in cessation of rectal prolapse.

Surgical therapy

A great deal of debate surrounds the optimal surgical management of rectal prolapse, and more than 100 procedures have been described in the literature. A single surgical operation is not appropriate for all patients with rectal prolapse.²⁸

Each technique has disadvantages and recurrence rates. No clear-cut indications for any procedure are known, no consensus on the operation of choice has been reached. The personal experience of the surgeon involved is the major determinant. However, elaborate operations are generally reserved for adults and are difficult to justify because of the safety and efficacy of relatively noninvasive procedures.

Surgical treatment can be done transanally (perineal approach) or transabdominally; transanal approaches have a lower morbidity, and abdominal approaches have a lower recurrence rate. Laparoscopy provides equal rectal fixation to open surgery, with less morbidity.

Abdominal repairs involve mobilization of the rectum and fixation to the anterior sacral wall, which can be done with sutures or with prosthetic material. Fixation with prosthesis may increase the incidence or stenosis and obstruction. In general, resection rectopexy has an acceptable recurrence rate (2-8%) but is associated with the added morbidity of a colorectal anastomosis.

Preoperative details

An acutely strangulated rectal prolapse should be covered with moist towels, and the patient should be brought to the emergency department. Occasionally, when a rectal prolapse is not reduced in a timely fashion, the progressive edema further precludes its reduction. This condition leads to rectal ischemia and necrosis, which warrants emergency surgical reduction, resection, or both.

The use of sugar has been described as an osmotic aid to reduce the edema and to allow the prolapsed rectum to be manually reduced to avoid emergency surgical intervention and to allow the patient to be treated electively under relatively stable conditions.²⁴ The sugar exerts a mild osmotic power over the prolapsed mucosa, helping the edema to slowly resolve, which allows for nontraumatic reduction and prevents complications. Sugar does not irritate the mucosa like other substances (eg, salt). The author has used sugar to reduce edematous prolapsed bowel in 8 patients. The edema resolves by as much as 50% in 30-90 minutes. The entire prolapsed mucosa must be covered with sugar, and the process can be repeated as many as 3 times. This technique allows the edema to resolve and improves the microcirculation on the affected segment, making it more favorable for any surgical procedure.

Injection sclerotherapy is a good initial procedure. This technique initiates an inflammatory reaction in the submucosal and perirectal tissues, resulting in fibrosis with subsequent cessation of the prolapse. This procedure can be performed on an outpatient basis with no need for bowel preparation. A wide variety of sclerosing agents have been used to treat rectal prolapse in children. Various materials are available for such injection; each has its advantages and complications. The success rates and complications of the treatment reported in the literature differ for each sclerosing agent.

In Spain, Ibanez et al (1997) used fibrin adhesive in patients aged 1 month to 8 years.²⁹ They reported no postinjection complications, and adequate sclerosis was accomplished in less than 24 hours.

In Egypt, Fahmy and Ezzelarab (2004) treated 130 children with rectal prolapse aged 6 months to 12 years.³⁰ Patients were divided into 3 groups. Group 1 was injected with 98% ethyl alcohol, group 2 was injected with phenol in almond oil 5%, and group 3 was injected with dextranomer and hyaluronic acid injectable gel (Deflux). Follow-up was 2 months to 3 years. Submucosal injection resulted in no mortality. In group 1, the recurrence rate was 11%; 2 patients had mucosal sloughing, and one girl developed a rectovaginal fistula. In group 2, 18% had abscesses and mucosal sloughing, and 2 developed perianal fistula. In group 3, 2 patients had immediate postoperative prolapse that spontaneously resolved. No patients had mucosal ulceration or abscess formation, and none had recurrence on long-term follow-up. Deflux had the lowest complication rate. Phenol in almond oil 5% had a high complication rate and should not be used. Alcohol is inexpensive and should be considered an alternative to Deflux.

In Turkey, Abes and Sarihan (2004) used 15% saline solution as an injected sclerosing agent in 16 children with rectal prolapse.⁶ Prolapse ceased in 93.7% of the children after the first injection. Only one patient required a second injection. No complications occurred. They concluded that 15% saline is preferable to other sclerosing agents because of the high cure rate, the safety of the procedure, the ease of injection, and the lack of complications.

Intraoperative details

For the injection of sclerosing agent, the patient is placed in the lithotomy or left lateral position under general anesthesia. A 20-gauge spinal needle is introduced through the anal mucosa using a proctoscope or it is externally introduced 2-3 cm from the anal margin, with a guiding finger in the anal canal, to several centimeters above the dentate line. Then, the sclerosant is circumferentially injected into the submucosal and perirectal space as the needle is withdrawn.  

Some of the surgical procedures available include the following:

• Thiersch procedure
• • Perianal sutures are subcutaneously placed as a cerclage. The principle is to create a mechanical barrier for the prolapse and to provoke an inflammatory reaction on the perirectal tissues that generates a fibrous ring rather than a toneless sphincter.
  • It is only a palliative procedure because it does not cure the prolapse itself and has a high recurrence rate in adults.
  • The Thiersch procedure is a good choice for children because it can be done with self-absorbing sutures to temporarily relieve symptoms until the base pathology is managed (see Media file 9).
  • Modifications with the use of knitted polypropylene mesh (Marlex mesh) or other nonabsorbing materials have been described (see Media file 10).²⁷
  • Saleem and Al-Momany reported a child who developed an acute scrotum one year after undergoing a Thiersch procedure, resulting from the spread of a perineal infection due to erosion of the wire used in the cerclage.³¹ This highlights the importance of following the patients until the wire is removed.  
• Delorme procedure: In the Delorme procedure, the mucosa and part of the underlying rectal muscle are excised, and the rectum is then plicated with polydioxanone sutures towards the anal canal. Long-term results are not satisfactory, with a recurrence rate of 17%.³² It has been used in children with recurrent prolapse and has the advantage of not entering the abdomen.
• Abdominal rectopexy: The rectum is mobilized and attached to the presacral fascia, using direct sutures or using a prosthetic material, a polypropylene mesh (Ripstein procedure; see Media file 11), or an Ivalon sponge (see Media file 12). It has a high success rate for prolapse control, and incontinence is improved in 60% of patients. As many as 60% of patients have constipation after this procedure.
• Perineal resection: Mikulicz first described this procedure in 1889.³ Perineal rectosigmoidectomy with rectopexy, correction of the pelvic floor (plication of the puborectalis muscles), and coloanal anastomosis is promising and could be a good approach for pediatric patients with intractable prolapse and redundant sigmoid. It has been successfully performed using stapling devices for the resection and reconstruction of the colonic continuity. This technique avoids the abdominal approach.

Other procedures include the following:

• Mucosal plication with anal encircling: This procedure routes Teflon tape relatively deeply outside the EAS.³³ Clinical results show a recurrence rate of 0-31% with no mortality and almost never any serious complications (eg, clinically significant bleeding or severe sepsis, which is occasionally encountered in other perineal procedures).
• Transsacral rectopexy: Transsacral (ie, Ekehorn) rectopexy involves placing a mattress suture from inside the rectum, through the lower part of the sacrum and out through the skin, where it is tied externally.³⁴ By leaving the suture in place for 10 days, local inflammation and infection causes adhesions between the rectal wall and perirectal tissues, binding them together (sacrorectopexy). The procedure takes less than 5 minutes and is reportedly 100% effective.³⁵
• Levator repair and posterior suspension: This is performed using a posterior sagittal approach. Nwako reported a 100% success rate with the Lockhart-Mummery procedure, which involves packing the presacral space with gauze through a posterior approach and excision of the prolapsed mucosa.³⁶ Hight et al (1982) recommend linear rectal cauterization of the anorectal mucosa; they had 98% success in 72 patients.³⁷
• Closed rectosacropexy: In Egypt, Lasheen (2003) described a technique of closed rectosacropexy to manage rectal prolapse in children.³⁸ The technique simply involves passing several U-shaped sutures through stab incisions made in the skin posterior to the anus, into the sacral fascia, then into the wall of rectum, down to the anal canal, and out through the stab incisions. The strands of the suture are tied subcutaneously through the stab incisions. This operation was successfully performed in 42 children (mean age, 3.5 y) who had recurrent rectal prolapse for 3-5 months. None of the children had any further recurrence or specific complications during follow-up of 1-3 years.
• Laparoscopic approach
• • Several authors have tried the laparoscopic approach to correct rectal prolapse.
  • Laparoscopic repair of rectal prolapse is technically feasible and can be performed with mortality and morbidity rates comparable to those of the conventional technique.
  • The procedure has a normal learning curve and initially has a slightly longer operative time.
  • According to Kairaluoma et al (2003), the main advantages of the laparoscopic approach appear to be a shortened hospital stay and reduced intraoperative blood loss.³⁹ The recurrence rate is not increased in the short term.
  • Lesser postoperative pain, better cosmesis, and a faster recovery of the bowel function and introduction of diet have also been reported.^{40, 41, 42}
  • Koivusalo performed 8 laparoscopic sacrorectopexies with good results.⁴¹ He reported 2 patients with postoperative constipation.
  • It appears that patients have less constipation and incontinence if the lateral rectal ligaments can be preserved, however, this requires further analysis.
  • Virtually every type of open transabdominal surgical approach to rectal prolapse has been accomplished laparoscopically. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis with or without rectopexy.
  • The growing body of literature suggests that laparoscopic surgical techniques can safely provide the benefits of low recurrence rates and improved functional outcome for patients with rectal prolapse.
  • Delaney reported 109 laparoscopic repairs in adults.⁴⁰ Hospital stay was 3 days (compared with 6 days for open surgery), and recurrence rates were 8% for laparoscopic surgery compared 5% for open surgery. The procedure is described as follows:
  • • The presacral space is entered, and the rectum is mobilized.
    • A precut mesh is passed down a port and tacked to the sacral promontory in the midline.
    • The edges are then sutured to the lateral mesorectal tissue for support.
    • In patients having a resection (those with slow intestinal transit and severe constipation), the upper rectum is transected with an endoscopic stapler and pulled out through a small left lower quadrant muscle splitting incision.
    • The resection is completed, and the anvil of a circular stapler is inserted in the proximal bowel before it is returned to the abdominal cavity.
    • The anastomosis to the rectal stump is performed before suturing the lateral mesorectal tissue to the promontory.
  • Saxena et al (2004) successfully treated a 22-month-old girl by using laparoscopic simple suture rectopexy with 5-mm instruments and with the use of two 3-0 nonabsorbable sutures on either side of the rectum to secure it to the presacral fascia.⁴³ No blood loss occurred, and the procedure was completed without complication. The child was followed up for 24 months, with good results.
• Acupuncture: Reports describe successful management of rectal prolapse with acupuncture.⁴⁴

Postoperative details

• Patients undergoing sclerosant injection are discharged the same day with simple analgesics and stool softeners.
• In procedures that include an abdominal approach and/or bowel resection, prophylactic antibiotics should be used, and the patient is discharged once bowel function has returned.

Follow-up

• Usually, only one follow-up visit is required to ascertain that the prolapse has ceased and the child has tolerated the procedure.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Complications of rectal prolapse include the following:

• Incarceration: Incarceration refers to the entrapment of the prolapsed intestine that makes it irreducible. This condition predisposes the patient to strangulation of the segment.
• Strangulation and gangrene: When rectal prolapse cannot be reduced in a timely fashion, the resulting edema further precludes its reduction to a point where the viability of the prolapsed segment is endangered. This condition is treated with emergency resection.
• Ulceration and hemorrhage: Trauma over the exposed mucosa produces ulcerations, bleeding, and mucous discharge. This occurs in approximately 12% of prolapsed patients. Treatment involves correction of straining and defecation habits.
• Prolapse rupture: Excoriation of the mucosa can perforate the prolapsed intestine. Urgent surgery is indicated for this complication.
• Mucosal prolapse: This can occur in 5-10% of cases postoperatively and is treated with elastic banding or excision under anesthesia.
• Incontinence: Incontinence should be observed for a period of 6-12 months because it is likely to spontaneously resolve. Postoperative perineal approach incontinence should be treated more aggressively.
• Postoperative recurrence: If the surgeon chooses to treat a recurrence with re-resection surgery, any prior anastomosis must be resected to avoid leaving an ischemic segment.
• Cancer risk: No clear correlation between colorectal tumors and rectal prolapse has been established. However, one study in adults demonstrated a 4.2-fold increase in the relative risk for rectal cancer in patients with rectal prolapse.⁴⁵
• Surgical complications: Surgical complications include postoperative pain, bleeding from the injection site, perirectal abscess formation, and a potential for damage to bladder neck or presacral nerve plexus. All of these complications are rare. Some children may have one or two further episodes of prolapse in the days immediately after injection before the prolapse resolution. As many as 12% of patients require a second injection, and as many as 8% need 3 injections. Failure rates may approach 15%.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

• After a surgical rectopexy, continence can be achieved in as many as 92% of patients. Resective procedures are associated with a decreased recurrence rate. Recovery of continence after surgery is not immediate and can take as long as 12 months.
• Nwako et al reported a 100% success rate with the Lockhart-Mummery procedure, which involves packing the presacral space with gauze through a posterior approach and excision of the prolapsed mucosa.³⁶
• Hight et al (1982) recommend linear rectal cauterization of the anorectal mucosa; they had 98% success in 72 patients.³⁷

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Some pediatric surgeons are reluctant to inject sclerosing solutions into a child's anorectum. The main concerns include the potential for harm by inducing fibrosis and the potential long-term risk for carcinogenicity. The benefit of using biofeedback in patients with chronic straining or paradoxical contractions of the anal sphincters is yet to be elucidated.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Media file 1:  Image of a young patient with a full-thickness rectal prolapse with multiple circular folds seen on the exposed mucosa.
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Media file 2:  Photograph of a severe rectal prolapse with clinically significant edema and mucosal ulceration.
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Media file 3:  Picture of an infant with full-thickness rectal prolapse. Severe edema and abundant mucus are seen on the mucosal surface.
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Media file 4:  The levator ani muscle is shown in red. It includes the ileococcygeus (stretches during defecation and labor), the pubococcygeus (integrity of the pelvic floor), and the puborectalis (closes the anorectal canal as a sling) muscles.
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Media file 5:  Deep, superficial, and subcutaneous external sphincter.
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Media file 6:  The anatomy of the internal and external anal sphincter mechanisms.
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Media file 7:  Image demonstrates mucosal prolapse, with radial folds seen on the mucosa.
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Media file 8:  Diagram depicting the clinical difference between a true (full-thickness) prolapse (left), including all layers of the rectum and with circular folds seen on the prolapsed intestine, versus a procidentia or mucosa-only prolapse (right) in which radial folds are seen in the mucosa.
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Media file 9:  Thiersch procedure. Perianal subcutaneous sutures create a mechanical barrier for the prolapse.
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Media file 10:  Lomas and Cooperman modified the Thiersch procedure by performing right anterior and left posterior radial incisions, encircling the anus with a Marlex mesh stripe, and tying it around a finger placed on the anal canal.27 Care must be taken to avoid perforating the posterior vaginal wall or the anterior rectal wall. The skin is closed, with the mesh left subcutaneously.
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Media file 11:  The Ripstein procedure is designed to maintain the normal posterior rectal curvature by attaching it to the presacral fascia, thus avoiding a straight tube that intussuscepts during straining. (A) The rectum is mobilized down to the coccyx. (B) A Marlex mesh placed around the rectum while this is tensed upward and sutured with nonabsorbable material to the presacral fascia. The loop of mesh needs to be loose enough to prevent postoperative constipation. (C) Sagittal view shows the suspended rectum. (D) The peritoneum is closed with a running absorbable suture.
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Media file 12:  Ivalon sponge procedure. (A) The rectum is mobilized. Meticulous hemostasis is mandatory to prevent a hematoma that predisposes the patient to prosthetic material infection. (B) An Ivalon rectangular sponge made of polyvinyl alcohol is sutured to the sacral periosteum. (C) The rectum is retracted upward, and the sponge is wrapped around it and tied to the anterior surface. A portion of the anterior rectal wall is left free to prevent luminal obliteration. (D) The peritoneum is closed with a running absorbable suture.
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REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

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Article Last Updated: Jan 10, 2008